LIFE IN THE END ZONE: A discussion of topical issues for anyone concerned with the final phase of life by Muriel R. Gillick, MD

May 29, 2017

Where Do All the Dollars Go?

The editor-in-chief of one of my
favorite health news sources, Kaiser Health News, recently published her first
book—for over twenty years she has been a journalist at the New York Times—and
it’s an important one. An American Sickness: How Healthcare Became Big Business
and How You Can Take it Back, by Elisabeth Rosenthal, is a powerful if somewhat monotonous
recounting of the evils of American health care. But it only seeks to explain
one weakness of contemporary American medicine, albeit an important one: it
costs too much. Or, more accurately, prices are too high. As Uwe Reinhardt put
it years ago, “it’s the prices, stupid.”

Understanding the behavior of
physicians, hospitals, drug companies, health insurers, and device
manufacturers, as this book seeks to do, is critical if we are to change the
system. The problem that they create, however, isn’t just that health care
costs consumers too much; it’s also that the quality lags behind what is
achievable—is evidenced by the poor standing of the US compared to other
developed countries. Failing to consider both quality and cost is
regrettable—we might, after all, be willing to tolerate the enrichment of drug
company shareholders if what we got in return was an excellent, if pricey,
product.

The
litany of shenanigans by big business may be familiar to many readers, but Rosenthal's comprehensive and detailed accounting is impressive and compelling. Consider the
first chapter on “the age of insurance.” The book recounts the story of how
the same treatment costs orders of magnitude more--$100,000 vs $19,000 per
medication infusion for a drug given monthly—when administered at NYU’s Langone
Medical Center than when provided at another nearby facility. For the patient,
whose treatment was covered by insurance, it didn’t much matter over the short
run. But for the system as a whole, and ultimately for all patients through
higher insurance premiums, it did matter. And the reason for the discrepancy is
that NYU negotiated a better deal with third party payers than did the
competition. What Rosenthal outlines but does not emphasize is that more
powerful hospital systems and physician researchers interact with (some might
say collude with) health insurance companies to produce this result. She
explains that because of an arrangement with the NYU researcher who was largely
responsible for creating the drug, NYU derived profit if total sales of the
drug exceed a particular threshold. By negotiating a very high payment for the
drug from the insurer, NYU is likely to exceed the threshold and cash in. So
it’s not just the motivations of physicians, hospitals, and insurance companies acting separately that impact the health care system; it’s the way all of these forces
work together that is crucial to achieving the end result.

Rosenthal presents one disturbing case after another. There’s the way hospitals
and physicians game the system to assure that patients essentially have to use out-of-network
providers when their insurance company will only cover in-network providers,
forcing patients to shoulder what can be enormous costs. There’s the notorious
“facility fee” that enables hospitals to charge insurers vastly more for a
simple procedure such as injecting anti-inflammatory medication into a joint if
it is done in an outpatient clinic than if it is done in a private office. What
she neglects to explain is the way the system conspires to provide what is
often inferior medical care to patients. Maybe this is more egregious with
older patients than younger ones, and her focus is overwhelmingly people who
aren’t enrolled in Medicare: either those with private insurance or no
insurance at all. The facility fee example, for instance, doesn’t just mean
higher costs. For a frail older person to get to a hospital clinic may mean
going by car, negotiating a confusing parking garage, and walking a
considerable distance from the garage to the office, none of which is so easy
if you’re 85, have severe arthritis (the reason for going for the joint
injection in the first place), and maybe have a little cognitive impairment to
boot. The enthusiasm for high tech procedures, driven in part by the
manufacturers of the devices used in the procedures, doesn’t merely drive up
costs: for vulnerable, older individuals, such technological intervention may
cause more harm than good. The anesthesia may result in confusion and the
hospital stay in functional decline—quite apart from the effect on the cost of
medical care.

Alas, the fixes the author proposes, the part of the book devoted to taking "health care back" from big business, aren’t going to fix the system. She calls
for creative insurance plan design, for example plans that cover
“essential” treatment fully and levy co-pays for “semi-elective” treatment.
That’s much like what the ACA does when it requires full coverage for preventive services
such as a screening colonoscopy, but allows the same colonoscopy to be billed
in full (if the patient has a high deductible health plan) if the procedure is ordered to remove a
cancerous polyp. Maybe that’s a good idea, although it leads to some bizarre
incentives—better to get that polyp removed at the end of the plan year, when
you might already have burned through your deductible, than at the beginning of
the year, when the growth might be more curable; better to say nothing to your doctor
about the blood you’ve noticed in your stools and just have a “screening test”
than to mention the blood and undergo the procedure to treat a “disease.” But
whether or not “benefit redesign” is a good idea—and one of the last major
benefit redesign ideas wasn't so thrilling, it was those very high deductible health plans that are
conquering the market—it’s not going to help patients now. Even the suggestions
that could, in principle, help right away, such as “demanding price
transparency” when getting an MRI, are a bit pie-in-the sky. You’re in the
doctor’s office and s/he wants you to get a scan right away. You’re supposed to
get a list of 5 centers that do MRIs and compare their prices? Really? What
about quality? What about accessibility of the image to your physician? What about transportation to these other sites?

An
American Sickness goes a long way to uncovering the workings of the health
system and for that it is to be lauded. It is extensively and for the most part
carefully researched, though there are errors. Rosenthal says pharmacists should be
able to prescribe birth control pills because they all have PhDs and shouldn’t
just be relegated to counting pills. Maybe they should be able to prescribe
birth control pills, but most pharmacists have a BPharm (a bachelor’s degree),
not a PhD. She says the website GoodRx allows comparison of prices for
prescription drugs only for Medicare patients. Maybe that was once true, but it
is no longer. But read this book for the insight it may give you on how the design of
the system affects outcomes. We will need to build on that scaffolding to investigate the full
range of systemic consequences—for quality as well as cost of health care, and
to engage in meaningful reform.